CMS-10510 Enrollment Data Guide

Basic Health
Program
Enrollment
Data
Requirements
for Federal
Payments
Centers for Medicare &
Medicaid Services
November 2015

Introduction
Section 1331 of the Affordable Care Act provides for the establishment of the Basic Health
Program (BHP), which is available to states to operate at their option. BHP provides affordable
health benefits coverage for individuals who are citizens or lawfully present non-citizens under
age 65 with household incomes between 133 percent and 200 percent of the Federal poverty
level (FPL), who are not otherwise eligible for Medicaid, the Children’s Health Insurance
Program (CHIP), or affordable employer sponsored coverage. People who are lawfully present
non-citizens who have income that does not exceed 133 percent of the FPL but who are unable
to qualify for Medicaid due to such non-citizen status, are also eligible to enroll. Federal funding
is available for BHP based on the amount of premium tax credit (PTC) and cost-sharing
reductions (CSR) that BHP enrollees would have received had they been enrolled in Qualified
Health Plans (QHPs) through the Marketplace. The Centers for Medicare & Medicaid Services
(CMS) published a BHP final rule and a payment methodology, the “Basic Health Program;
Federal Funding Methodology for Program Year 2015” on March 12, 2014 (CMS-2380-FN) that
outlines more specifics of the BHP program requirements and the funding methods.
As described further in the BHP final rule, CMS will publish, on an annual basis, a proposed and
final payment notice with the federal funding methodology for a given BHP program year. The
notices will contain the methodology and data sources CMS will use to determine the federal
BHP payments for the year. To date, CMS has published a payment notice for 2015 and 2016.1
Based on the most recent payment methodologies, the federal BHP payment will be calculated
by “rate cells.” Each rate cell will represent a unique combination of the following factors:
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age range;
geographic rating area;
coverage category (for example, self-only, two-adult coverage or two-adults with one or
more adult children);
household size; and
income range as a percentage of the federal poverty level (FPL).

The total federal BHP payment will be equal to the sum of the number of enrollees in each rate
cell multiplied by the federal BHP payment rate for that rate cell.
CMS is requesting enrollment data from each state on a quarterly basis that contains the data
elements that will be needed to calculate the federal BHP payment. In addition, a limited
amount of other information to verify and to organize the data is also requested.

1

Basic Health Program; Federal Funding Methodology for Program Year 2015. http://www.gpo.gov/fdsys/pkg/FR2014-03-12/pdf/2014-05257.pdf
Basic Health Program; Federal Funding Methodology for Program Year 2016. http://www.gpo.gov/fdsys/pkg/FR2015-02-24/pdf/2015-03662.pdf

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Instructions
1. States must report data for all individuals for whom the state has made a complete and
accurate eligibility determination in accordance with BHP regulations at 42 C.F.R. §
600.320, 340 & 345 and who were enrolled in BHP in the previous quarter.
2. Recognizing that data elements can change for an enrollee over the course of a quarter
(e.g., due to a change in household income, move to another county of residence, etc.),
states should report data from the first calendar day of the quarter. For persons who
become enrolled in the second or third month of the quarter, states should report data
from the first calendar day of the first month of the quarter in which the person was
enrolled.
3. States must retain records to support a claim that an individual is BHP-eligible and
enrolled in a Standard Health Plan. This could include records of an eligibility
determination or redetermination, using the standards described in the state’s BHP
Blueprint, and monthly BHP enrollment records that include the individual.
4. CMS will provide an Excel workbook that can be used to report the data for 2015 and
will work with states to consider other possible means to report this data in future
years. The workbook will display all requested data elements.
5. Please include a description of each Data Element on the Data Dictionary tab of the
workbook.
6. States must comply with CMS Enterprise File Transfer (EFT) system requirements,
including all privacy and security standards, as described in the Information Exchange
Agreement Between The Centers for Medicare & Medicaid Services And Medicaid/CHIP
Agencies For The Disclosure of Information for Administration of Insurance Affordability
Programs.
7. State reports are due to CMS no later than 60 days after the close of the quarter.
8. States must submit a signed and dated BHP Enrollment Data State Attestation Form,
included here as Attachment A, with their data submissions.

Enrollment data elements
CMS is requesting that states submit quarterly enrollment data for each person covered by
BHP, including the following specific data elements. Where possible, CMS is requesting data
elements that are already collected and defined by the health insurance exchanges or state
Medicaid programs. Sample specifications for these data elements have been provided below;
however, states may suggest alternatives subject to CMS approval.

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1. Personal identifier
A personal identifier would allow CMS to have a specific count of the number of enrollees
and ensure that there are no duplicate enrollees in the BHP program. An appropriate
personal identifier might include an enrollee’s Social Security Number or a unique
Marketplace or Medicaid identification number. Please specify in the Data Dictionary
whether the personal identifier is the same identifier as is used in the Exchange or
Medicaid. A person should retain the same personal identifier throughout the duration of
their BHP eligibility.
2. Family identifier
The family identifier for each person enrolled in BHP in the household will allow individuals
to be matched to a specific household. The personal identifier of the head of the household
may be used as the family identifier. This would be used to calculate the estimated
premium tax credit the household would have received if enrolled in a QHP in the Exchange.
3. Date of birth
The date of birth of the enrollee is needed in order to determine the age of the enrollee.
This is used to confirm eligibility and determine the appropriate rate cell for payment
purposes. This may be reported as month, day, and year of birth (e.g., xx/xx/xxxx).
4. County of residence
The county of residence of the enrollee is required in order to determine the geographic
rating area of the enrollee. States must report the name of the enrollee’s county of
residence and its National Bureau of Standards Federal Information Processing Standards
(FIPS) numeric code.
5. Indian Status
The Indian status of the enrollee is needed because Indians receive different levels of costsharing reduction subsidies in the Exchange. The state should report whether an individual
has an Indian status consistent with the definition used for the Exchange at 45 C.F.R. §
155.300 and defined as follows:
 a member of any Indian tribe, band, nation, or other organized group or community,
including any Alaska Native village or regional or village corporation as defined in or
established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688),
which is recognized as eligible for the special programs and services provided by the
United States to Indians because of their status as Indians; and,
 would be eligible under the special eligibility standards and process for Indians as
described in 45 C.F.R. §155.350(a) (with the exception that they are enrolled in a
Standard Health Plan rather than a Qualified Health Plan).
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This may be reported as “Y” for enrollees who indicate that they are members of a
federally-recognized tribe and “N” for all other enrollees.
6. Family size
The state must report the size of the enrollee’s family.
For tax filer households, family size should be consistent with the definition used for the
Exchange at Section 36B(d)(1) of the Internal Revenue Code (42 C.F.R. § 600.5). That is, a tax
filer’s household must include the taxpayer, his or her spouse when filing jointly, and
whoever the taxpayer expects to claim as a tax dependent in his or her federal income tax
return in the coverage year. A tax dependent’s household includes the enrollee who
expects to be claimed as a tax dependent for the coverage year and whoever is claiming
him or her as a tax dependent.
For non-filer households for this reporting period, household size definition should be
consistent with that used in the Medicaid non-filer rules as defined at 42 C.F.R. §
435.603(f)(3). That is, for an adult enrolling in coverage, the household must include: the
adult; the adult’s married spouse if living with the individual; and the adult’s natural,
adopted, and step-children under age 19 (or at state option, age 19 or 20 if a full time
student) if living with the adult. For a child enrolling coverage, the household must include:
the child under age 19 (or at state option, age 19 or 20 if a full time student); any of the
child’s parents (biological, adoptive and step-parents), if living with the child; and any of the
child’s siblings (biological, adoptive and step-siblings), who are under age 19 (or at state
option age 19 or 20 if a full-time student). CMS is further analyzing the impact of non-filer
rules on payment and additional data and/or a payment adjustment may be required in the
future.
For both filers and non-filers, this data element may be reported as a numeric value
representing the household count (e.g., 1, 2, 3).
7. Household income
The annual MAGI household income of the enrollee’s household is needed to determine
premium tax credits and cost-sharing reduction subsidies in the exchanges. The state should
submit verified household income from the enrollee’s last eligibility determination, unless
the enrollee reports a change in income during the quarter. In that instance, the new
income amount should be reported at start of the next quarter. The income reported
should be as consistent as possible with their income if they had applied to enroll in
coverage in the marketplace.
For tax filer households, the MAGI household income definition should be consistent with
that used for the Exchange in Section 36B(d)(2) of the Internal Revenue Code. That is,
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‘household income’ means, with respect to any taxpayer, an amount equal to the sum of
the MAGI income for all the members of the household.
For non-filer households for this reporting period, CMS is permitting use of Medicaid nonfiler rules. Household size and income definitions should be consistent with that used in the
Medicaid non-filer rules as defined at 42 C.F.R. § 435.603(d) & (e).
For both filers and non-filers, this data element may be reported as a numeric value
representing the annual MAGI income used to determine eligibility for BHP enrollees (e.g.,
dollar amount to two decimal points).
8. Number of persons in household enrolled in BHP (Coverage Family)
The number of persons in the household who are enrolled in BHP should be reported to
determine the cost of the premium for the household. This must be reported as a numeric
value representing the number of individuals in the household enrolled in BHP (e.g., 1, 2, 3).
9. Months of coverage
The enrollment status for each month of BHP-eligible coverage of the quarter should be
reported. The state can report whether or not a person was enrolled in BHP for each month
of the year.
Months of coverage means, any month where, as of the first day of the month, the
individual or family is eligible, enrolled and covered by a BHP standard health plan
described in Subpart E of Part 600 of 42 CFR and the premium for such coverage is paid by
the state. This data must be provided as a sequential binary indicator showing the
enrollment status in each month of the quarter (e.g., 1 = enrolled, 0 = not enrolled).
10. Plan information
Some information about the standard health plan in which the beneficiary is enrolled must
be reported for the purposes of oversight/program integrity activities. This may include the
issuer name, plan name, and, where available, a standard plan identification number (e.g.,
HIOS ID, NAIC-issued Payer ID). The state must describe which elements they are providing
in the Data Dictionary tab of the workbook.

Sample Spreadsheet
CMS has developed a sample spreadsheet for data submissions during the periods that the
state reports estimated and actual enrollment. CMS will prepare a workbook that can be used
to report this data for 2015 and will work with states to consider other possible means to
report this data.
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Attachment A: BHP Enrollment Data State Attestation Form

I certify that:
1. I am the Governor of the state or his/her authorized designee to submit this BHP
Enrollment Data File (hereinafter “File”).
2. This File contains enrollment data only for individuals eligible for and enrolled in the
Basic Health Program under Section 1331 of the Affordable Care Act and as such are
eligible for payment to the BHP Trust Fund for the quarter indicated on the spreadsheet.
3. The data contained in this File are based on actual recorded BHP-enrolled individuals in
the state and are not based on estimates.
4. The information in this File is correct to the best of my knowledge and belief.

___________________________________________
Signature/Date

____________________________________________
Name/Title

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